What families need to know about opioid misuse and treatment during pregnancy

PREGNANCYamp OPIOIDS

Parent Helpline 1-855-DRUGFREE wwwdrugfreeorg

22

PREGNANCY amp OPIOIDS

INTRODUCTION

Is there a young woman in your life who is pregnant and misusing or addicted to opioids Perhaps itrsquos your daughter or granddaughter your sonrsquos girlfriend or wife a niece or a friend Here yoursquoll find information to help her have a healthy pregnancy and a healthy baby

You along with family and friends may be worried about her opioid use and how it might affect her baby Opioids include heroin fentanyl and prescription pain medications like Oxycontinreg Vicodinreg and Percocetreg

An addiction to opioids is called an opioid use disorder and it is a treatable illness With comprehensive treatment and good prenatal care the mother-to-be can reduce the risks to both herself and the baby

In this guide you will find information about helping the mother-to-be with comprehensive prenatal care treatment delivery newborn health breastfeeding social supports and what to expect in the weeks and months after delivery

As someone who cares about the mother and her baby you have an opportunity to offer help and support to start her on the road to recovery and to deliver a healthy child

Parent Helpline 1-855-DRUGFREE wwwdrugfreeorg

22

PREGNANCY amp OPIOIDS

INTRODUCTION

Is there a young woman in your life who is pregnant and misusing or addicted to opioids Perhaps itrsquos your daughter or granddaughter your sonrsquos girlfriend or wife a niece or a friend Here yoursquoll find information to help her have a healthy pregnancy and a healthy baby

You along with family and friends may be worried about her opioid use and how it might affect her baby Opioids include heroin fentanyl and prescription pain medications like Oxycontinreg Vicodinreg and Percocetreg

An addiction to opioids is called an opioid use disorder and it is a treatable illness With comprehensive treatment and good prenatal care the mother-to-be can reduce the risks to both herself and the baby

In this guide you will find information about helping the mother-to-be with comprehensive prenatal care treatment delivery newborn health breastfeeding social supports and what to expect in the weeks and months after delivery

As someone who cares about the mother and her baby you have an opportunity to offer help and support to start her on the road to recovery and to deliver a healthy child

Parent Helpline 1-855-DRUGFREE wwwdrugfreeorg

33

PREGNANCY amp OPIOIDS

WHATrsquoS INSIDE THIS GUIDE

First Acknowledge How You Are Feeling 4

Next Understand the Stigma Discrimination and Prejudice 5

Get Her to the Doctor 6

Get Her to Treatment 6

Quitting Cold Turkey Can Be Risky 8

Medication-Assisted Treatment Is Recommended 8

Help Her Prepare for Delivery 10

Potential Involvement of Child Protective Services 11

Newborn Health 12

Breastfeeding Is Encouraged 14

The Weeks and Months After Delivery 14

There Is a Risk of Relapse and Overdose Get Life-Saving Medicine Naloxone 15

Acknowledge the Challenges You Are Facing 16

Conclusion 18

Resources 19

Notes of Appreciation20

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44

PREGNANCY amp OPIOIDS

First Acknowledge How You Are Feeling

You may have mixed feelings about this pregnancy You might

feel excited to welcome a new life into the world and yet worried

about the well-being of the mother and child You may feel fear

or even anger Perhaps yoursquore becoming a grandparent and are

concerned that your ldquogolden yearsrdquo of retirement will vanish

as you will now be in the position of raising this child You may

feel challenged at convincing the mother-to-be that she needs

prenatal care treatment for her opioid use with recommended

medications and to stop using illicit drugs

Know that these feelings are normal You are not alone in

experiencing ambivalence or negative thoughts and emotions

WHAT YOU CAN DO

bull Find others who are going through what you are going through Seek out Nar-Anon Families Anonymous or other support groups for people who have family members struggling with substance use

bull Remember to take care of yourself Find time to do things you enjoy and that are relaxing restorative and that bring you joy

bull If you find yourself becoming depressed or extremely anxious seek help from a mental health professional It may be helpful to find a therapist who specializes in cognitive therapy a type of therapy that teaches practical ways to cope with persistent and unwanted thoughts

Parent Helpline 1-855-DRUGFREE wwwdrugfreeorg

55

PREGNANCY amp OPIOIDS

Next Understand the Stigma Discrimination and Prejudice

The mother-to-be may face harsh judgment from others including the medical community but dont let this dissuade her from seeking treatment and support ldquoThere is huge stigma for pregnant women who are addicted to opioidsrdquo explains Dr Adam Bisaga MD Research Scientist New York State Psychiatric Institute and Professor of Psychiatry Columbia University Medical Center ldquoTherersquos already stigma with addiction Therersquos already stigma with addiction in women Therersquos even more stigma with addiction in pregnant women This can deter a woman from getting good treatment and seeking helprdquo

Keep in mind that the mother herself may be feeling ambivalent about the pregnancy One study indicates that 86 percent of pregnancies in women with an opioid use disorder are unplanned

WHAT YOU CAN DO

bull Offer compassion and reassurance and listen without judgment

bull Be mindful of the words you use For example words like ldquojunkierdquo and ldquoaddictrdquo can be hurtful Instead you can say ldquoperson with an opioid use disorderrdquo Read more about words

to use and not use

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PREGNANCY amp OPIOIDS

Get Her to the Doctor

ldquoAs with any pregnancy patients need good obstetric carerdquo explains Dr Bisaga ldquoThe patient should tell the obstetrician of her addiction and have someone monitoring the pregnancy She should see them as soon as possible and get regular checkups She and the baby will have a healthier outcome the sooner she starts to see a doctorrdquo

WHAT YOU CAN DO

bull Encourage her to receive immediate and regular prenatal care from providers who are knowledgeable about the impact of substance use during pregnancy

bull To find a helpful and supportive provider ask around in the recovery community -- or ask the provider what his or her view of addiction is to see if theyrsquore the right fit

bull Provide support by accompanying her to prenatal care appointments if possible

bull Encourage a healthy lifestyle good nutrition relaxation and stress-relief techniques such as meditation and light exercise if approved by her provider

Get Her to Treatment

The mother-to-be will also need treatment to address her physical psychological emotional and social issues in addition to her opioid use Nineteen states have funded treatment programs for pregnant women The Substance Abuse and Mental Health Services Administration (SAMHSA) maintains a treatment finder

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PREGNANCY amp OPIOIDS

where you can search for pregnancy and post-partum programs across the country

The mother-to-be may also need mental health treatment as an estimated 50 to 80 percent of pregnant women with an opioid use disorder also have another mental health disorder In many if not most cases trauma-informed care is needed as well This is a treatment framework that involves understanding recognizing and responding to the effects of all types of trauma Trauma-informed care emphasizes physical psychological and emotional safety and helps survivors rebuild a sense of control and empowerment

Keep in mind that pregnant women who misuse opioids are at increased risk for pregnancy-associated complications and death Untreated substance use disorders have been linked to high-risk behaviors such as prostitution and crime which can expose pregnant women to sexually transmitted diseases violence legal problems and incarceration Itrsquos essential that the mother-to-be gets proper treatment for her opioid use disorder and gets good medical care for herself and her baby

WHAT YOU CAN DO

bull Help her find trauma-informed addiction treatment Search the SAMHSA treatment finder for pregnancy and post-partum programs across the country

bull Help her find mental health treatment if needed which you can also find at the SAMHSA treatment finder Its important that her substance use and any other mental health problems are addressed simultaneously

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88

PREGNANCY amp OPIOIDS

Quitting Cold Turkey Can Be Risky

Some women who become pregnant while using opioids want to detox (allowing their body to rid itself of drugs) on their own as a way to stop using heroin or pain medicines This is risky however Studies have shown that 8 out of 10 women return to drug use within a month after detoxing on their own and are at greater risk of overdose

In addition going off opioids too quickly during pregnancy can be dangerous to the baby If the pregnant woman suddenly quits cold turkey the fetus also experiences withdrawal which might increase the risk for premature labor fetal distress and miscarriage

WHAT YOU CAN DO

bull Discourage detoxing on her own

bull Help her find addiction treatment See page 6 for where to find it and what to look for

Medication-Assisted Treatment is Recommended The use of medication-assisted treatment (MAT) during pregnancy is the recommended best practice for the care of pregnant women with opioid use disorders MAT is the use of medications in combination with social support and counseling to treat her substance use disorder Counseling helps people avoid and cope with situations that might lead to relapse

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99

PREGNANCY amp OPIOIDS

Most doctors treat opioid disorders in pregnant women with either methadone or buprenorphine (often prescribed as buprenorphinenaloxone) These medications prevent withdrawal reduce cravings and reduce the euphoria associated with illicit use MAT has been shown to improve outcomes related to maternal adherence to prenatal care improve nutrition and better infant birth weights as well as reduce exposure to infections from IV drug use such as HIV and Hepatitis C

Under medical supervision methadone or buprenorphine can reduce the risk of pregnancy complications These medications are safe for the baby and also allow the mother-to-be to focus on prenatal care and her opioid use disorder treatment and recovery program

Treatment involves taking medications in prescribed doses during pregnancy and after the baby is born Methadone is only available in specialized clinics Buprenorphine may be available from a primary care physician or obstetrician if they have received special training

Decisions about the right course of treatment are best made by each woman with the help of doctors and providers who specialize in treating pregnant women For example her doctor may need to increase her dose of medicine in the third trimester of pregnancy and then can go back to the lower dose after pregnancy

Note There are currently no adequate or controlled studies on whether naltrexone (brand name Vivitrolreg) is safe during qpregnancy Studies suggest that if a woman is already stable on Vivitrolreg she should continue treatment so as not to destabilize recovery

Parent Helpline 1-855-DRUGFREE wwwdrugfreeorg

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PREGNANCY amp OPIOIDS

WHAT YOU CAN DO

bull Call your state health and human services department specializing in substance use to find a facility that offers treatment for pregnant women with methadone or check out the Suboxone Treatment Provider Locator

bull Encourage the mother-to-be to begin treatment with medications

bull Participate in family therapy if available

Note Medically supervised detox may be considered in women who do not accept MAT or when treatment is unavailable In that case a doctor experienced in treating prenatal addiction should supervise care with informed consent of the woman Help Her Prepare for Delivery

ldquoDelivery is usually no different than any other pregnancyrdquo says Dr Bisaga ldquoBut itrsquos important to prepare in advancerdquo This involves ensuring your doctor and hospital have experience in methadone and buprenorphine during labor and delivery Each patient needs a pain management plan for childbirth and delivery Methadone or buprenorphine will not treat her pain The mother-to-be should discuss pain control with her physician during her prenatal care She must also let the doctors at the hospital know that she is taking methadone or buprenorphine so they donrsquot give her labor pain medications that could cause withdrawal

Women on methadone and buprenorphine may require pain medication after birth especially if they require a Caesarian

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PREGNANCY amp OPIOIDS

section This can involve a combination of non-opioid pain medications such as ibuprofen and acetaminophen as well as short-acting opioids in addition to their usual maintenance dose of methadone or buprenorphine If a woman on MAT requires opioid pain medication she should be sure to discuss this with her MAT provider and should dispose of any remaining medication appropriately when no longer needed

The mother-to-be should also select a doctor for the baby (a pediatrician or family physician) and meet before delivery to talk about the care of her baby

WHAT YOU CAN DO

bull Encourage her to discuss a pain management plan with her doctor

bull Help her find a qualified and caring pediatrician or family physician for her baby mdash sometimes called ldquorecovery friendly pediatric practicesrdquo

Potential Involvement of Child Protective Services

Laws vary considerably from state to state regarding testing pregnant women suspected of substance use as well as reporting requirements to child welfare Further many babies and mothers get tested for drugs and alcohol at delivery which may include methadone and buprenorphine Having a positive drug test even if itrsquos for prescribed medications may mean that social workers or a child protection agency will want to talk with the mother and her family A child services worker may come to the motherrsquos home to see how safe the

Parent Helpline 1-855-DRUGFREE wwwdrugfreeorg

1212

PREGNANCY amp OPIOIDS

environment is for her baby In most cases child protection services strive to keep the family together

WHAT YOU CAN DO

bull Offer your emotional support

bull Encourage the continuation of substance use treatment relapse prevention and a healthy lifestyle

Newborn Health

Babies exposed to heroin or prescription opioids prenatally can have temporary withdrawal or abstinence symptoms called Neonatal Abstinence Syndrome (NAS) These withdrawal symptoms may also occur in babies whose mothers take methadone or buprenorphine although its important to note that not all babies experience NAS NAS is a treatable condition

Signs and symptoms can be different for every baby with NAS Most appear within 72 hours of birth and can include shaking and tremors poor feeding or sucking incessant crying fever vomiting and sleep problems

ldquoSome babies may have some discomfort related to withdrawal in the very short termrdquo explains Dr Bisaga ldquoBut in the long term they are no different than other babiesrdquo

NAS can be reduced by ldquorooming inrdquo with the mother breastfeeding swaddling skin-to-skin contact (holding baby bare chest to bare chest) and sometimes giving the baby medications

The baby will be checked every few hours over the first three to four days after birth Morphine is one common medication used

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PREGNANCY amp OPIOIDS

while some hospitals use methadone or even a tincture of opium The babyrsquos dosage is decreased over time until the symptoms have stopped The baby may need to stay in the hospital for a few days or weeks while taking the medication

ldquoBabies exposed to opiates require the same supports that all babies deserve mdash a safe and loving home lots of interaction and attention regular sleep feeding and playrdquo explains Dr Steven H Chapman General Academic Pediatrics Director of the Boyle Community Pediatrics Program Childrenrsquos Hospital at Dartmouth-Hitchcock and Director of Child Health Center for Addiction Recovery Pregnancy and Parenting In addition opiate-exposed babies deserve early intervention developmental services and may experience more difficulty gaining weight Engagement with a recovery friendly pediatric practice is an excellent idea With the proper love and supports many if not most grow up healthy and strongrdquo

WHAT YOU CAN DO

bull Encourage the new mother to ldquoroom inrdquo with her baby mdash breastfeed swaddle and hold her baby with skin-to-skin contact which can all help with NAS symptoms

bull Make sure the mother identifies a pediatrician who has experience with NAS and can link her to appropriate care for the infant

bull Offer ongoing encouragement and reassure her that NAS symptoms are usually short-term and give the mother support and help with caring for her child Every parent can benefit from parenting classes and support Link her to such resources in the area

bull Help get the mother and child involved in services that focus on enriching the babyrsquos early experiences and help improve the quality of the babyrsquos home environment

Director of the Boyle Community Pediatrics Program Childrens Hospital at Dartmouth-Hitchcock and Director of Child Health Center for Addiction Recovery Pregnancy and Parenting

Parent Helpline 1-855-DRUGFREE wwwdrugfreeorg

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PREGNANCY amp OPIOIDS

Breastfeeding Is Encouraged

Breastfeeding is safe and usually encouraged for women who are taking methadone or buprenorphine However breastfeeding is not safe for women with HIV who are taking certain medicines (check with the doctor) or who have relapsed and are actively using drugs

Breastfeeding has been shown to reduce the severity of NAS It also has many other benefits for mothers and babies (such as being held and active sucking) The Weeks and Months After Delivery ldquoThe patient will need support for how to be a mother and how to take care of her childrdquo says Dr Bisaga ldquoThis is needed for when shersquos doing well and for when shersquos not doing wellrdquo

The weeks and months after the baby is born can be a stressful time for women in recovery The new mother should be sure to continue treatment for her substance use disorder attend parenting support programs and counselingrelapse prevention programs

The new mother should not make a decision to stop her methadone or buprenorphine too quickly or too soon because this increases the risk of relapse It is important for her to discuss decisions about her medication with her doctors

The postpartum period is already a vulnerable time for new moms in general as they face the stresses of sleep deprivation caring for a newborn and possibly symptoms of postpartum depression said Maria Mascola MD in an American College of Obstetricians and Gynecologists news release Women with opioid use disorder

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PREGNANCY amp OPIOIDS

are dealing with all those things in addition to the challenges of their addiction which mdash without treatment and support mdash can often lead to relapserdquo

WHAT YOU CAN DO

bull Encourage her to talk to her medical team regarding any desired changes in medications

bull Offer to help care for the baby while the new mother attends counseling especially if there are signs of postpartum depression and other support programs

There is a Risk of Relapse and Overdose Get Life-Saving Medicine Naloxone

One of the biggest risks of opioid use disorder is overdose If the mother-to-benew mother relapses and takes too much of an opioid her breathing may slow down or stop and she could die Naloxone (brand name Narcan) is a drug that stops the effects of opioids when used in time Itrsquos important to have Naloxone on hand as a precautionary measure in case she relapses mdash it can save her life if she overdoses

WHAT YOU CAN DO

bull Make sure you have naloxone on hand and know how to use it

bull Ask her provider to write a prescription for naloxone or a referral to a public health program which dispenses it Many independent and chain pharmacies now offer Naloxone without a prescription

Parent Helpline 1-855-DRUGFREE wwwdrugfreeorg

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PREGNANCY amp OPIOIDS

Acknowledge the Challenges You Face

You may be facing several challenges with the mother-to-benew mother Here are suggestions for how you can help

CHALLENGE 1 She may be reluctant to engage in treatment

WHAT YOU CAN DO

Listen for ldquoChange Talk This means if your loved one expresses a concern over the way things are or voices a desire to improve her life take notice and help her connect the dots beginning the conversation about treatment Compassionately explain how her substance use is related to her concerns in the present and her hopes for a better future Try to be respectful without becoming confrontational

CHALLENGE 2 You may be concerned about paying for treatment especially if the mother-to-be does not have health insurance

WHAT YOU CAN DO

Although it may take work and patience finding affordable

treatment for the mother-to-be it is possible Research state programs sign up for Medicaid look into programs offered by religious groups or create a crowdfunding platform to raise the money you need to help the mother-to-be receive treatment services

Parent Helpline 1-855-DRUGFREE wwwdrugfreeorg

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PREGNANCY amp OPIOIDS

CHALLENGE 3 States vary in terms of how child welfare laws apply to pregnant women engaged in illicit substance use or misuse You and your loved one may be concerned about related legal ramifications

WHAT YOU CAN DO

Check the laws and child welfare statutes in your state to know if the mother-to-be is at risk for consequences and then seek out facilities that are likely to help minimize those risks Sometimes if the mom-to-be is doing well it can help her case You can also contact the National Advocates for

Pregnant Women CHALLENGE 4 You may be worried about the well-being of the mother and baby

WHAT YOU CAN DO

Offer as much help and support as you can to the mother and baby Encourage the mother to build a support community by asking for help from the caring people in her life

ldquoThere is a circle of support that all babies and mothers needrdquo explains Dr Chapman ldquoNo one does it alone Some have lots of grandparent help some neighbors or friends some aunts or cousins Some use foster care for short periods to help babies and to give mothers the chance to care for themselves and some are adopted Adopted babies can still have a strong and positive relationship with their birth motherrdquo

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PREGNANCY amp OPIOIDS

CHALLENGE 5 Just as the mother-to-be may be face the stigma prejudice and discrimination of addiction so may her surrounding family and friends You many feel consumed by her substance-related problems You may feel overwhelmed with fear anger resentment shame and guilt

WHAT YOU CAN DO

Remember to take care of yourself not only to help you but also to model healthy behaviors for your loved one and the new baby

Self-care can make you feel better and improve your relationships with others When you feel better and more optimistic yoursquore more resilient meaning you can adapt and roll with lifersquos ups and downs better without falling into despair or getting angry when the mother-to-be has a setback

Self-care can look different to everyone Seek out whatever it is that you enjoy doing (exercise reading watching a movie taking a hot bath etc) Anything that will fortify your mind body and soul You canrsquot afford not to take care of yourself

Conclusion

With your support encouragement and reassurance along with good medical care the mother-to-be can have a healthy pregnancy and deliver a healthy baby

And the baby with developmental support good pediatric well-child care and a healthy nurturing and caring environment will grow into a healthy child

Parent Helpline 1-855-DRUGFREE wwwdrugfreeorg

1919

PREGNANCY amp OPIOIDS

Resources

Get One-on-One Help to Address Your Childrsquos Substance Use httpsdrugfreeorgarticleget-one-on-one-help

Medication-Assisted Treatment httpsdrugfreeorgarticlemedication-assisted-treatment

Treatment of Opioid Use Disorders in Pregnancyhttpsncsacwsamhsagovresourcesopioid-use-disorders-and-medication-assisted-treatmenttreatment-of-opioid-use-disorders-in-pregnancyaspx

Patient Education Fact Sheet (ACOG) httpswwwacogorgPatientsFAQsImportant-Information-About-Opioid-Use-Disorder-and-Pregnancy

State-by-state listing of Womenrsquos Substance Abuse Service Coordinators to help find providershttpwwwcffuturesorgfileswebinar-handoutsSSA-WSN-CFSR20Coordinator20Directorypdf

Childbirth Breastfeeding and Infant Care (ASAM)httppcss-oorgwp-contentuploads201510ASAM-WAGBrochure-Opioid-Labor_Finalpdf

Pregnancy Methadone and Buprenorphine (PCSS-O)httppcss-oorgwp-contentuploads201510ASAM-WAGBrochure-Opioid-Labor_Finalpdf

Methadone Treatment for Pregnant Women (SAMHSA)httpsstoresamhsagovproductMethadone-Treatment-for-Pregnant-WomenSMA14-4124

Neonatal Abstinence Syndrome (NIH)httpswwwnlmnihgovmedlineplusencyarticle007313htm

Decisions in Recovery Treatment for Opioid Use Disorder (SAMHSA)httpsstoresamhsagovshincontentSMA16-4993SMA16-4993pdf

Substance Use During Pregnancy (Guttmacher Institute)httpswwwguttmacherorgstate-policyexploresubstance-use-during-pregnancy

Learn more about your statersquos laws about opioid use and pregnancy (Guttmacher Institute) wwwguttmacherorgstatecenterspibsspib_SADPpdf

Substance Use During Pregnancy State Laws and Policieshttpswwwguttmacherorgstate-policyexploresubstance-use-during-pregnancy

Parent Helpline 1-855-DRUGFREE wwwdrugfreeorg

2020

PREGNANCY amp OPIOIDS

Note of Appreciation

This guide was informed by discussions with Dr Adam Bisaga MD Research Scientist New York State Psychiatric Institute and Professor of Psychiatry Columbia University Medical Center

We are grateful to the following for their expert review of this guide

Steven H Chapman MD General Academic Pediatrics Director Boyle Community Pediatrics Program Dartmouth Hitchcock Medical Center President NH Chapter AAP and the team at the Center for Addiction Recovery Pregnancy and Parenting at Dartmouth-Hitchcock

Julia R Frew M D Director of the Center for Addiction Recovery Pregnancy and Parenting and Moms in Recovery Program at Dartmouth-Hitchcock

Hendreacutee Jones PhD University of North Carolina at Chapel Hill School of Medicine Department of Obstetrics and Gynecology and the UNC Horizons Program

We greatly appreciate their generosity in sharing their time and expertise to inform parents and loved ones how to best support a young woman in their life who is pregnant and misusing or addicted to opioids

Additional sources used in preparing this guide

American College of Obstetricians and Gynecologists (ACOG) American Society of Addiction Medicine ASAMNational Institutes of Health (NIH) Providersrsquo Clinical Support System For Opioid Therapies (PCSS-O)Substance Abuse and Mental Health Services Administration (SAMHSA)